Inquiry into how one of 10 affected patients was given wrong dose after chemotherapy bungle was discovered

THREE days after a doctor discovered 10 Adelaide cancer patients were being given the wrong dose of chemotherapy, the error was repeated — and the affected patient’s distress is “beyond description”.

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THE chemotherapy bungle has deepened with the State Government calling an inquiry into how one of 10 affected patients was given the wrong dose of treatment three days after the error was discovered.

After reassuring the public the mistake had been fixed the day after it had been discovered, Health Minister Jack Snelling said to be told otherwise by The Advertiser was unacceptable, explaining: “I was told that this error was fixed by the 20th of January. To find out a patient appears to have been given a lower than intended dosage days after this date is unacceptable.”

The acute myeloid leukaemia patient, who is distressed and seeking legal advice, began his second course of “consolidation” chemotherapy at Flinders Medical Centre on January 22, three days after a senior clinician at the Royal Adelaide Hospital discovered the error on January 19.

“They had three days to make sure I got the correct last treatment,” the patient said.

“The distress that causes me is beyond description.”

Diary notes seen by The Advertiser show the patient, a man in his 60s, was admitted on January 22 for about five days for his second round of treatment. He completed his first round of the wrong dose several days earlier, before the mistake was discovered.

“If they’d notified Flinders immediately, I know from the people there they’d have reacted immediately and I would have got the proper dose,” he said.

“I would have been short on the first dose but infinitely better off on the second.”

The patient, already angered by the Government’s “callous” handling of the bungle, said he was left feeling his chances of recovering from serious illness had been jeopardised.

“Had they known (at Flinders) they would have been able to turn around and say, ‘Oh my god, we’ve buggered up the first one but we’re going to do this right and we’re going to do it now’,” he said.

Mr Snelling yesterday confirmed the patient appeared to have been given the wrong dose of the drug Cytarabine and ordered an independent review into how this happened after the mistake — the result of a typo entered into the treatment protocols relied on by doctors and pharmacists — had been revealed. The inquiry will be carried out by the chair of the Australian Commission on Safety and Quality in Healthcare, Professor Villis Marshall AC.

The devastated patient said he was concerned the RAH may have withheld information while they worked out a strategy with their insurers, adding: “That clearly has to have put me at much greater risk.”

In a letter of apology sent to Flinders patients — it is understood there were five at FMC and five at the RAH — the hospital said the wrong dose was administered between July 2014 and February 2015, supporting the view FMC was not told until well after January 19.

It is understood a second patient at FMC, who was treated before the mistake was known, was in hospital with an infection in late January and was told around January 28, a full week after the error was first uncovered.

The first patient was not told of the mistake until mid-February when he was called in and arrangements made for top-up chemotherapy which began later that month. The man said he would seek advice on his legal position because he had his family to think of.

Slater and Gordon personal injury lawyer Tim Downie said patients given the wrong dose might be able to seek compensation.

“If a patient can prove that the duty of care owed was breached and that they suffered injury as a result, then they are generally entitled to compensation,” Mr Downie said.